I’ve enjoyed The BMJ’s focus on societal causes of ill health recently and Dr Lucinda Hiam et al’s article deeply resonated with me. Mainly because as a GP, I’ve always been troubled by my colleagues, often well meaning, but equally tone deaf, rhetoric of “personal responsibility” with regard to health promotion.
“To lose weight, feel great and reduce the burden on the health system, just eat 5 veg/fruit a day, healthy fats, enough protein, no UPFs. Get your zone 2, 5 and strength training in. Meditate. Sunlight in your eyes. It’s free!”
For an upper-middle class family without historic trauma or current adversity this might be useful in isolation. But let’s take the case of a patient I spoke to in my clinic last week.
She was a young, single mum, early school leaver, on universal credit. Her child has chronic health issues and she presented with anxiety, exhaustion and insomnia. Her council flat is covered in black mould that is poisoning both her and her child, meaning she can’t work from the stress. She’s overweight, low income, and uses food banks.
Yes, she may benefit from lifestyle advice to detoxify the mould and manage her sleep, weight and stress but what she really needs is good quality housing, enough money to buy food and a job market that can work around her skills and passions. She needed more support as a child, not years of austerity. She doesn’t need a clinician to tell her to ‘pull her socks up’ and take responsibility for her health. She needs investment now to compensate for what she didn’t have for the last fourteen years of cuts. And she needs empathy and support in this process, not blame and shame.
Nationwide the figures mentioned are shocking. In 2022, 3.8 million people including one million children were destitute (doing without two or more of six essential items: housing, heat, light, food, clothing and toiletries). The number of children in food poverty doubled between 2022 and 2023. Health inequalities have been growing over the last decade due to poor investment and the political ideology of (vulgar) individualism and accusations of nanny state. It results in blaming people for succumbing to poor health as a way of deflecting from lack of funding.
Since posting my views on this topic on LinkedIn I have received a wealth of supportive comments and Direct Messages from colleagues in general practice, public health and from the general public.
However, a senior medical officer in the Army wrote a counter argument that having seen people in more deprived conditions worldwide take responsibility for their health problems despite adversity, people in the UK need to be grateful.
As LinkedIn is not usually a space for debate, I welcomed this comment as it represents an argument many clinicians have to this widespread issue:
“Be grateful for what you have – someone is always worse off in comparison”
Gratitude in the right context can be a powerful, positive emotion that can increase wellbeing and decrease stress. Barbara Fredrickson is a world expert on positive emotions and through her ‘broaden and build’ theory, feelings of gratitude both broaden the extent of positive experiences in a given moment but also build strength like a muscle working in the gym to compound positive states over time.
The problem is gratitude, and any positive emotions need a degree of psychological and physical safety present to be authentic. Forcing yourself to feel positive when circumstances are overwhelmingly negative is deemed “toxic positivity” which is detrimental to happiness and agency.
As a clinician, if someone admits they are struggling they need to be heard. Telling someone they need to be grateful is not respecting the pain they are in. It’s not empathising. It’s closing down. It’s trying to find the quickest solution based on your impression of global events. This may help to sooth your own distress but will do nothing to help the person if they need to be heard and understood first. This is definitely an example of when trying to help, doesn’t help.
So as clinicians we need to take a moment before we tell people to just ‘take more responsibility.’ We need to get into their shoes. We need to appreciate their barriers. No, we shouldn’t hold back from giving important lifestyle advice, but we need to avoid hidden blaming and shaming in the process. And together, we need to push for huge investment in improving the social determinants of health to avoid worsening the already catastrophic demand for healthcare we are facing in GP and OP clinics, A&Es, hospitals and social placements.
As Dr Hiam writes. “A common response is that we can’t afford such action – we argue, we cannot afford inaction.”
Dr Tom Gedman – GP & Cognitive Therapist
15th July 2024
